Tezepelumab-ekko (Tezspire) (CPB 1003, reviewed 2026-08-06)

IMMEDIATE ACTIONS REQUIRED: (1) Before 2026-08-06, update billing software to REQUIRE precertification for all J2356 (Tezspire) claims submitted to Aetna commercial plans. Configure system to block claims without precert. (2) Billing team must establish precertification workflow: route all Tezspire requests to Aetna at (866) 752-7021 or fax (888) 267-3277 BEFORE service delivery. (3) Update encounter forms and provider EHR templates to display mandatory prescriber restrictions: Asthma claims require allergist/immunologist OR pulmonologist; CRSwNP claims require allergist/immunologist OR otolaryngologist. (4) Add clinical criteria validation checklist in billing system to ensure: (a) for asthma — prior biologic use in past 12 months documented OR all severity criteria met (exacerbations, hospitalization, inadequate control on high-dose ICS + additional controller); (b) for CRSwNP — bilateral nasal polyps documented via endoscopy/CT/clinical scoring AND prior surgery or systemic corticosteroid failure documented. (5) Flag claims that show concurrent use of J2356 with other biologics (J0517, J2182, J2357, J2786, etc.) — these will be denied per policy. (6) Update continuation-of-therapy review process: at 3-month intervals, request clinical documentation showing symptom/exacerbation reduction or corticosteroid dose reduction to justify ongoing coverage. Failure to submit precertification will result in claim denial.